This week I wanted to review the only way the body knows how to heal: inflammation.
It gets a bad rap, usually juxtaposed with the words chronic and pain to label an injury, or remarks/comments for a conversation. Inflammation is seldom used in a positive context. So let's give inflammation a pep talk and vouch for its mediators, its guidance to tissues for repair and its ability to be diverse, effective and efficient in the healing process.
Anatomy Doesn’t Lie
(Smith, Kruger, Smith, & Myburgh, 2008)
I recently reviewed my notes from a lecture delivered by Professor Tim Watson at IFOMPT 2016 and I loved his passion for the inflammatory process. He has one of the best quotes about inflammation.
He discusses this process in great depth, like it is a best friend! I have listed some of the basic anatomical facts in the chart below.
|Chemical Mediators of Inflammation|
|Pre-Formed and Stored||Plasma Source||Newly Synthesized|
|Lysomal Enzymes||Platelet Activating Factors|
Recreated from Dr. Watson’s Lecture
Smith et. al. (Smith et al., 2008) describe over 70 chemical mediators which guide healing in the muscle repair process alone! Dr. Watson reported over 102.
The basic fact is, there's a growing body of evidence that our physical therapy interventions influence the expression and release of inflammatory mediators and impact directly inflammatory events. The question is, how is current understanding of this processed utilized in the clinic to influence it in a positive?
The Body Heals in a Predicable Manner
We have all studied the common sequence of repair
- Bleeding (immediate)
- Inflammation (3-5 days)
- Proliferation (12-20 days)
- Remodeling (over 20-30 days)
THIS IS NOT WHAT HAPPENS! It is one continuous sequence and has been segmented for educational purposes only. This is not to say we can’t respect the timeframes, but we have to remember, what we see in the clinic is typically not a true representation of the inflammatory process, it is usually inflammation gone awry.
There can be as many as 12 chemical markers activated by exercise, movement and manual therapy--these markers have a direct and positive impact on the laying down of healthy collagen. They guide future inflammatory response, proliferation and remodeling simultaneously. Make sure you explain this to patients.
We know that manual therapy and an appropriate matched exercise will create a:
- Mechanical Effect
- Gross physiological effect
- Neurological effect
- Chemical effect
- Bioelectric effect.
This combination of factors has a more complicated explanation, but you can see that appropriate activity will change tissue. The process will happen regardless, but we have to be able to assist it through appropriate activity, modalities and most importantly guide the patient on how to promote optimal healing.
Pain is in the Brain
If you get a chance this week, listen to this interview of Dr. Atul Gawande (one of my favorite authors) by Sara Kliff (another favorite health care policy analysts). He discusses the current opioid epidemic, takes ownership for the medical profession’s contribution to the current crisis, and as a surgeon, describes how he has changed his interaction with patients' post-operative care, both in his words and prescriptions. Pain is a normal response to a surgical intervention, and the medical profession from the mid-90s viewed pain as something to avoid at all costs. He mentions an astounding fact that if a person is prescribed an opioid medication for one week, there is an eight percent chance they will still be receiving a prescription for opioids one year later. Our words will create expectations for patients to either experience greater pain or less pain, let’s choose them wisely.
We are Prone to Clinical Reasoning Errors During a Busy Clinic Day
I think one of the biggest errors made currently in our patient management, outside of using inflammation in a negative sense, is our discussion with patients about over the counter anti-inflammatories. Patients will casually mention using Ibuprofen for example and we accept it. It has been well documented since the 1980s that NSAIDs …
- Delayed/prolonged healing.
- Increase the chance of complication (25% of people taking Ibuprofen will develop ulcers, and the interesting fact is that the ulcers will be delayed in healing by the Ibuprofen)
- Slowing down of inhibiting of angiogenesis, a key process in sequencing and repair.
- Inhibition of prostaglandin synthesis.
Yet, every commercial for these medications states the benefits of having pain free movement through self-medication. The New York Times published an article in 2012 entitled For Athletes Risks from Ibuprofen Use, which I encourage you to provide your patients, and explain to them that it has been known for almost 40 years that these medications delay healing and have can very harmful effects.
Treat the Person and You Win Every Time
The next time you have a patient who is concerned about their “chronic inflammation,” have an honest discussion with them. Let them know that inflammation is healing and that it bathes the injured tissue with everything it needs to repair. I tell some patients that inflammation is so enthusiastic it “hugs the area” too much, and pain results (noxious mechanoreceptors and chemoreceptors are activated in this process). Also, I let them know that pain should not always be avoided, 0/10 and 100% are not possible in an aging body for the most part, and it is healthy to have some pain. Basically, you want to push an area to create a callous not a blister.
A Little Deeper
Dr. Watson's website is chocked full of articles about inflammation and I highly recommend it. There are a lot of great reads here.
For more in depth conversations and to take your own clinical reasoning and manual therapy skills to the next level, browse NAIOMT's course schedule and join us! Have a great week!
Terry Pratt, PT, MS, COMT, FAAOMPT
Clinical Faculty for North American Institute of Orthopaedic Manual Therapy
Smith, C., Kruger, M. J., Smith, R. M., & Myburgh, K. H. (2008). The inflammatory response to skeletal muscle injury: Illuminating complexities. Sports Medicine, 38(11), 947–969. https://doi.org/10.2165/00007256-200838110-00005
Tim, W. (2016). Soft Tissue Repair and Healing Review. Electrotherapy Today, 1(1), 16. Retrieved from http://www.electrotherapy.org/modality/soft-tissue-repair-and-healing-review